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HomeMy WebLinkAbout04-2243INRE: DANIEL ALLY IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL TERM PETITION FOR APPROVAL OF MINOR PLAINTIFF'S COMPROMISE SETTLEMENT Pursuant to Pa. R.C.P. No. 2039, Chris and Me~na Ally, as parents and natural guardians of Daniel Ally, file this Petition for Court Approval of their son's settlement and in support avers as follows: 1. Petitioners, Chris and Meena Ally are adult individuals residing at 3411 Hawthorne Drive, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Petitioners are the parents and natural guardians of Minor Plaintiff Daniel Ally who resides with them and who is 13-years old, having been bom on May 15, 1990. 3. Minor Daniel Ally has selected Petitioners, as his parents and natural guardians, to represent his interests in this Petition. 4. At all relevant times hereto, United Services Automobile Association ("USAA") was the homeowner's insurer for Michael and Lynn Placzek who reside at 219 Wood Street, Camp Hill, Cumberland County, Pennsylvania, 17011. 5. On July 18, 2001, Daniel was visiting the Placzeks' son at the Placzeks' aforesaid home address. 6. During the visit to the home, Daniel was swinging on a swing set in the backyard of the Placzek's home when he was bit on the left calf by the Placzeks' dog. A true and correct Document #302775.1 copy of the Animal Bite Report for this incident is attached hereto as Exhibit "A" and incorporated herein by reference. 7. The Petitioners are claiming that the Placzeks were liable for the dog attack based on theories of negligence and violations of the Pennsylvania Dog Law found at 3 P.S. § 459-101 et seq. 8. As a result of this dog attack, Petitioners made a claim to USAA who insures the Placzeks for this incident. 9. As a result of the dog bite, Daniel was taken to Holy Spirit Hospital Emergency Room on July 18, 2001 where the physician reported that Daniel sustained a 1.5-inch left calf laceration laterally. 10. At the hospital, Daniel received seven sutures, was given a prescription for an antibiotic and was instructed to return in 12-14 days for suture removal, which he did. A ta'ue and correct copy of the hospital records are attached hereto as Exhibit "B" and incorporated herein by reference. 11. Since his suture removal, Daniel has not received any further medical treatment. 12. Daniel's medical expenses for the treatment set forth above total $608.75. Loomis Insurance Company has paid $462.00 and Petitioners have paid the remaining $25.00. A lien in the mount of $462.00 has been asserted and negotiated so that Loomis will be paid back the sum of $341.92 in satisfaction of its lien. A copy of the letter dated April 7, 2004 from Loomis accepting the reduced sum is attached hereto as Exhibit "C" and incorporated herein by reference. 13. Daniel is a 13-year old boy and has no wage loss claim. 302775-1 14. As a result of the dog bite, Daniel has been left with a scar on his left calf, which will likely be permanent. A tree and correct color reprint of a photograph of that scar taken on June 13, 2003 is attached hereto as Exhibit "D" and incorporated herein by reference. 15. On behalf of its insureds the Placzeks, USAA has agreed to pay $15,000.00 to Daniel and Petitioners to resolve the liability claim against the Placzeks as a result of this dog bite. A tree and correct copy of the letter offering the $15,000.00 is attached hereto as Exhibit "E" and incorporated herein by reference. 16. The Petitioners, after consultation with counsel, determined it is in the best interest of Daniel to accept USAA's offer on behalf of its insureds and seek Court approval of the same. 17. Counsel was retained by Petitioners to represent Daniel on a contingent fee basis of 25% of gross recovery. A true and correct copy of the Fee Agreement is attached hereto as Exhibit "F" and incorporated herein by reference. Counsel's attorney fee at 25% would be $3,750.00. In addition, counsel has also incurred the following expenses in pursuing this claim on behalf of Daniel: Filing Fees $ 55.50 Photocopies $ 8.29 Postage $12.71 Long Distance Phone Calls $ .70 Fax $14.00 Miscellaneous $ 50.00 18. TOTAL $141.20 Petitioners respectfully requests that this Honorable Court approve of the compromise settlement of this claim with USAA and the Placzeks in the gross amount of $15,000.00, out of which Petitioners will receive the sum of $10,766.88 on behalf of Daniel, Loomis will receive the sum of $341.92 and counsel will receive the sum of $ 3,891.20 for attorney fees and costs. 302775ol 19. Petitioners propose to place their son's settlement proceeds in a federally insured account at a bank, credit union or savings and loan association organized or existing under the laws of the Commonwealth of Permsylvania in name of their son. 20. Petitioners desire the funds to be made available to their son when he attains his eighteenth birthday on May 15, 2008 except as authorized by prior Order of this court. 21. Petitioners also have been requested to sign the Release attached hereto as Exhibit "G' and incorporated herein by reference, upon approval of the settlement, which would release the Placzeks and their liability insurer from any further claims by Daniel or on his behalf as a result of incident at issue. 22. Petitioners also desire to discontinue the action filed in this matter upon filing of the Proof of Deposit with the Court. 23. USAA, on behalf of its insureds, the Plaezeks, concur with the filing of this Petition and also seek approval of the minor settlement under the terms set forth above. WHEREFORE, the Petitioners respectfully request that this Honorable Court approve of the settlement and enter an Order distributing the funds as follows: (1) To be paid to Chris and Meena Ally, parents and natural guardians of Daniel Ally, for the purposes of this Order, to be placed in an insured savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Daniel Ally reached his majority on May 15, 2008, except upon prior Order of the Court", the sum of $10,000.00; (2) To be paid to Chris and Meena Ally, parents and natural guardians of Daniel Ally, the sum of $766.88 for the immediate benefit of Daniel Ally; (3)To be paid to Loomis Company, for satisfaction of the medical lien - the sum of $341.92; and (4) To be paid to Metzger Wickersham, P.C. for counsel fees and expenses - the sum orS 3,891.20. METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Dated: May 17, 2004 By: Clark DeVere, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-0300 (717) 238-8187 Attorney for Petitioners ANIMAL BITE ~PORT ~ ~1 tl Phone (Home) ~1¢~ 0~$ (Work) T~e of amm~l {~ Dug~ Cato O~cr~ ~ddrcs= Tetanus O I.-tP,[O O HDCV (Rabies V~.ccmc) 0 Other O Phone ~ 7 *.. ' '436 0 Phone Date Report Reeehed b) DOH Lo~ ho HSH ER FORM REO DATE: 07/1.-~/01 15:40 PT#: 17212606 NAME: ALLY ,DANIEL A SS #: ADDRESS: 225 WOOD STREET /CAMP HILL f~A/17011 BIRTHDATE: 05/15/19~0 AGE: 11 SEX: M MS: S RACE: 5 EMPLOYER: CHILD OCCUPATION: ADDRESS: / / / PH# CHURCH: NONE AMB: NONE COMMENT: NAME: ADDRESS: MR#: 461764 717 730-0888 OEO: EMERGENCY CONTACT INFORMATION ALLY ,MEENA REL TO PT: M WK PH 225 WOOD STREET /CAMP HILL /PA/17©ll PH 717 - 730-088S NAME: ADDRESS: REL TO PT: WK PH - / / / PH - ADMIT OR: ATTND DR: REFER DR: ADMIT DX: COMPLAINT: AMB BRT COMMENT: ~! /7 CASE INFORMATION 111~-~ SHARMA~ANdANA REO SOURCE: EO PATIENT TYPE: 111936 SHA~A~RANdANA HOSP SERV: ER3 FINANCIAL CLS: ~ t~~ VISIT CLINIC CODE: ER3 ICD-9 DX: DO~ BITE LT LED IN BY: BRT IN BY: MOTHER E I ACCIDENT INFORMATION DATE/TIME: 07/18/01 14:30 ACC INO: 0 JOB RELATED: N LOCATION: D£SCRIPTION: PT WAS BIT ON HIS CT LEO BY T HE NEIGHBOR'S DOG GUARANTOR INFORMATION NAME: ALLY ,MEENA PT REL TO OUAR: 0 SS #: 109-74-37~t. ADDRESS: 225 WOOD STREET /CAMP HILL /PA/17011 PH 717 - 7~0-0888 EMPLOYER: HOLT SPIRIT HOSPITAL CONTACT NAME: ADDRESS: 503 N 21ST ~TREET /CAMP HILL /PA/17011 PH 717 - 763-2167 INSURANCE INFORMATION INSURANCE 00 COB POLICY # SUBSCRIBER REL F'C VFY CARD PRECERT/AUTH # PLAN GROUP # PRECERT PHONE # N Y (~Jl 0 - INSUR.ADDRESS: 2 Zg~ COMM. INS I/P & O/P I 0726427~9 ~j.O ALLY ,WAZIRCH O Y Y ~qO~.O - 3INSUR.ADDRESS: 850 PARK RD PO BOX 7 WYOMISSINO ~}~'~ PA iq&lO INSUB.ADDRESS: ~ ~ INSUR.ADDRESS: ~O'- COMMENTS: PMD/NONE PT DID NOT HAVE INS CARD AT RE GISTRATION ~ATI~NT NAME: ALLY ~DANIEL A ~ PT#: 17212606 MR#: 461764 '"OIST~RED BY: FHMAF EDITED BY: DATE: END OF DOCUMENT 15:41 07/18/01 FROM HOD4,ER~REOSF1 CONSENI'TO MEDICAL TREATMENT I HEREE~Y CONSENT AND AUTHORIZE Hnly Sp~rft Hospital, ds agents, and'employees, to the rendenng of medical care, which may mctude routine d~agnostlc ~rocedures and such medical treatment as my afl'ending er consulting phymc~an considers to be necessary I also under- stand ~t is customary, absent emergency or extraordinary cFcumstances, that no substantial procedures will be pedormed upon me unless or until I have had an opportunity to discuss them have the nght to consent or refuse to consent t understand that the practice of medicine and surgery m not an exact science and that dlagno- sm and treatment may ~nvolve nsks of ~nlury or even death and acknowledge that no guarantee has been made to me as to the results of any examlnabon or treatment In this I understand many of the phymc~ans on the staff of Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent contractom who have been granted the pnvdege of using these facflihee for the care and treatment of their patients Fdrther, I realize this Hoepffal ~s a teaching Hospital and at the Hospital are health care personnel m training who, unless expressly requested otherwise, may participate or may be present during my care as part ct their education St~ll or motion p~ctures and closed circuit momtormg of patient care may also be used for educational purposes, unless I expressly request othenN~se I understand that in order to ensura a safe environment for patients, visitors and staff all properly on the premises of Hold, Spirit Hospital is subject to reasonable search and/or seizure at any time wdhout further notice RELEASE OF MEDICAL INFORMATION t authorrze Holy Sprat Hospstaf to release to requesting heatth msurence c~mer(el, these representatives and audrtors, end any refernng hearth care providers, such d~agnoshc and therapeutic information 0ncledmg any mformat~on relating to treatment' for alcohol and substance ~tbuse and/or treatment of osvch~atnc d~sorders, and/or cor~fldentlal HIV related Informat~ as may be necessary for them to determine benefit enid- dement, to process payment claims for health care services provided dunng this f}osp~tahzet~on/treatment episode, and for continuing care/treatment A photocopy or carbon copy ef th~a authonzatmn shall be considered as effechve and valid as the ongmal The undersigned also authorizes Medicare, when apphcable, to release to another insurance carrier, upon their request, medical ~nformat~on needed to make I understand and consent that the manufacturer of any implantable dewce inserted by my physician dunng the course of..6~y%'ucgery/p~cedure may be provided w~th my ~dentqf[cebon mtormatlon, including social secunty number, as mandated by Federal Law INSURANCE ASSIGNMENT OF BENEFITS I authonze payment directly te Holy Sprat Hospital and my treating phys~cmns of all benefits payable under my msurance~.C~es .~n~erstand I am responsible to the Hospital and phymmans for all charges not covered by, this asmgnment STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITSTO PROVIDERS, PHYSICIANS AND PATIENT ~ request payment of Authonzed Medicare benefits to me or on my behalf for any.servlcas furmshed me by or in Holy Spirit Hospital including physician serwces ~ authonze any holder of medical and other ~ntomnatran about me, to release to Medicare and ~ts agencies any mformat~on needed to determine these benefits for related services Initials MEDICAL ASSISTANCE RECIPIENT My s~gnaturas certifies that I received a service or rtems from Holy Sprat Hosprtal and Dr an the date hated below I understand that payment for this Serwce or ~tem wlfl be from Federal and State funds, end that any false claims, statements, or documents, or conceaJment of material may be prosecuted under apphcabte Federal and State Laws J u~3derstand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non covered charges Aisc, I agree that if at the hme of serwce, ~f I am not eligible for Medical Ass,stance, I wdl be resporks~ble for balances owed to Holy Spirit Hospital Irstlals _ I have read and understand each of the secbona contained above I understand that by signing this document, I am agreeing and providing the authorization/consent contained m each of the above sections where my initials are located I have had the opportuni- ty took questions re.oardlng_e0ch of these sections and all such questions asked have been answered to my sehsfactren. Relstrenshlp to Patient Time Date /~/~-¢/ HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSENT FOR TREATMENT/RELEASE OF INFORMATION [NSURANCE AS$tGNMENT CHART COPY ADM, DATE: 07/18/2001 HISTORY: The patient ~s an 11-year-old ma~e who was swinging on a swing set th~s afternoon with h~s fnend when h~s fnend's pet dot jumped up and b~t h~m ~n the leg as he was swrng~ng He sustained a 1 5 tach laceration over the left calf laterally He presents for evaluation and treatment H~s tetanus status is up to date The dog has been vaccinated PAST MEDICAL HISTORY: Unremarkable MEDICATIONS: None ALLERGIES: None PHYSICAL EXAM VITAL SIGNS: Blood pressure 111/62, pu~se 76, respiratory rate '18 He's afebnle LOWER EXTREMITIES: aspect of the left calf The patient has a 1 5 ~r]ch laceration over the lateral HOSPITAl- COURSE: The wound was cleansed and ~mgated w~th normal saline and cleansed w~th Betad~ne x's 3 The wound edges were approximated using 4-0 Prolene suture Seven throws were required to approximate the wound edges Pabent tolerated procedura well The wound was then dressed w~th stenle gauze and tnple antibiotic o~ntment PLAN: The pabent was ~nstructed to keep the wound clean and dry and to use Tylenol for any d~scomfort He was g~ven a prescription for Augmentm for 5 days for prophylaxis and was ~nstructed to return for suture removal in 12-14 days or sooner ~f there was any sign of ~nfectlon S~gned BRADLEY K DAVIDSON, M D 08/01/2001 20 29 BRADLEY K DAVIDSON, M D BD/am DOC # 161459 D 07/'18/2001 T 07/26/2001 8 52 A 004028 HOLY SPIRIT HOSPITAL Camp Hdl, PA 17011 Page 1 of 1 NAME Ally, Darnel A MR# 461764 ROOM# ER3 EMERGENCY ROOM REPORT ORIGINAL Initial Lab ~& X-l~y Orders: Labs I A~Tr [ 1 Radlolo~ly S~eclal Procedures: IT~HR (BOR) ( ] Sternum Ultrasound: CT: (W=Wlth contrast; WO=WIthout) ] Abdomen [ ] Abdome~JPekns W WO [ ] VQ Scan ] Duplex Doppler [ I Brain/Head W WO [ t EC~3- ] Gallbladder [ ) Chest W WO cardiogram ]Pelvtc/ [ ] Spiral chest for PE Trar~svagmal [ ] Other REASON Specimens/Cultures ] Beta Strap AG Rapid Billing Classification. [ 1Stoc~ o & P FACILITY CHARGE [ I Level I [ ].e~c~ent ( I ~ve~ tt [ 1 MediCal [ ] Level 111 [ ] Case 1 [ ] Level IV [ ] Extended Hfs Holy Spirit Hospital Camp Hill, PA Physlcmn Order Sheet CHART COPY Card/sc (' ] Monitor I l EKG [ ] 02 .... LJM~n [ I Respiratory Tx [ ] 02 Satural~on Medlcatmna / IV's / Additional Orders IV: NSS/DSW/LR/DS/.45NS/D5 9NS WOIKVO/Infuse at mia/hr [ ] Obt,,in old records [ ] Td R~plratory [ ] ASGIs [ ] Peak Flows IBelore/Affer Reap Tx [ } Protocol Imtsatcd lot: Initials. Signature RN/MA II~lats' ~ Signature RN/MA Dlclated Half [ ] Completed [ ] CRITICAL CARE _ hrs Dlagnoatm Impresamn. Place inju~ occurred [ ] H~e [ ] Indus~ ~ecmaban [ ] MVA [ ] Other ~ ..... *~;JVITAL SIGNS Pulse ~ ~ Tamp ~') ..O PAIN SCALE .Re~,plratmns ~ B/p/////(.,. Z.. Pulse Ox -- Immunizations UTD [ IN [ ]Y Lest Tetanus I.~J*~,~ LMP H~ patient been exposed ~n Ihs pa~ month,,)o m~sles, ch~ckenpox orT~? [~ [ I Y I ]UNK ArethereAdv~nceDirec~ves~ [ ]N/A [~ [ ]Y Are c, opms awdabfe? [ ]N/A [ IN [ ]Y ObJecave [/~0 x 3 /Resp,ral,ons Symmet~,cal & unl.bored /] Sk,n temperature & cC~or WNL Weight ~ ~estlmate (If pertinent) Last Do~e Medication/Dose/Frequency Last Dose Past Medical/Surgical History Deehnat,on [ ] U~'"'} ER Intermediate [ ] ER Triage es,-~essmant completed at /~ ~ by ~ '- ~ R N Admlsaon Ca,e~. [ } Admission [ ~ O~e~a~lon ~ [ ] O~ Re~; Sent [ ] C~thmg ~eet ~mp[eled D~spos~,on ~H~ ] AMA ~ ] OR at / ~sfa~o~ ~rqve~ ~n~a~ ~ /10 [.] G~tlCal [ ] ~c~e Holy Spiral Haapltal Camp HJII, PA 17011 CHART COPY ) .raton _ [ ] N/a, Locat ~3r'd~adfatlon Intensity (scale 1-10) [ ] Mon~tor/P, hyl~m ~ _ Respirator/ I ] Symmetncal & Unlabored [ ] Lungs c~ear [ ] Sharlow [ ] WheezJng [ ] L [ ] R [ ] Laboce<FOyspne~c [ ] Rales~Rhonch~ [ ) L [ ] R [ ] R®tracflons [ ] Stndo~ [ ] Cough [ ] Non-productve [ ] Productive S{~tum colo¢ -- [ 1 JVD [ ] Capillary refill Rapid [ I Delayed [ I [ ] Oxygen [ ] NC [ ] Mask L/Min $aO2 Skin { I WNL [ ] Extremlt®~/Pedal Edema { ] Pale/Ashen [ ~ Hot [ ] Cyanotic [ ] Flushed [ ] Dlaphomtc [ ] J~und~ce [ ] Cool [ [ BnJises [ ] Other [ 1 Rash Neuro [ ] AAO x 3 [ ] PERL EENT Confused Hysten~al [ ] Ap~pnete [ ] Delayed/~sent Demos ~ln or symptoms [ ]NA ~m throat Nasal ~est~ [ ] Earache [iL[iR Ep~smms [iL[iR Headache Photophobla San< neck D~zzlness/Syncope Numbness~'lnghrlg Weakness { ] Gnps equal [ ] Gnps unequal BlurTed w$10n Bummglpam Redness [ J OD [ ] 0S D~scharge []OD[]O$ Gl [ ] Denies pa~n or symptoms [ } N/A Para location/red,eton [ ] Nausea [ ] Olan~ea [ ] Hematemes~s Last BM [ ] Bowel sounds [ ] Abd distended [ 10the~ GU/GYN [ ] Demos para or symptoms [ I N/A [ ] Frequency [ ] Urethral d~scharge [ ] Urgency [ ] Vaginal discharge [ ] Dysuna [ ] Vag{nal bleeding [ ] Hematuna LMP [ ] Retenbo~ Other Trauma [ ] N/A [ ] Location [ ] Abrasions [ ] Swelhng [ ] Bums [ ] Otter [ ] S~era,ls up X2 [ ] Call bell handy I i ER proc4~dure explained [ l EKG -RN li31tlals T~me Done TIME TO RADIOLOGY ~RETURNED FROM RADIOLOGY TIME AMOUNT SOLUTION GAUGE SITE RATE ATTEMPTS CONDiTiON RN ~nltlal$ TIME MEblC/ flON/E OS ,GE ROUTE TIME VITAL SIGNS · l;fO NURSES' NOTES SITE RN ~nlt,als PT RESPONSE/PAIN SCALE INITIALS SIGNATURES INITIALS SIGNATURES HOLY SPIRIT HOSPITAL CAMP HILL, PA John R. Dletz Emergency Center Patient Documentation and Flow Record 2o5 ECU 12/00 CHART COPY ( ) DISCHARGE I~NS~RUCTIONS HOLY SPIRIT : pa~t ~M~matloa ~ ~n }m~nt I~f~t~ ~ review ~ HOLY SPIRIT HOSPITAL EMERGENCY CENTER $03 NORTH 21ST STREET CA~P HILL, PA 1701Z-2288 (?1~r) 763-2516 ( ) Toothache Continue pre~ent med~cettons except Use Ac~ll ()bupro~en) or Tylenol as ne~ for para, fear a~or~ng ~ package ins~cttons for age, weight NECESSARY APPROVAL ( ) Follow-up wt~h ( ) Urgl Center ( ) Suture removal SPRAINS, STRAINS, BRUISES, FRACTURES ( ) For a~lw~ as nsed~ ( ) Apply mist heat f~ mJn~es_ braes dmiy ) ~ght Du~ until conbnuous~y, return ~f breeding not c~tmlled phymcmn will be conta~ed i~ there is a chan~ m the HOLY SPIRIT HOSPYI'AL EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 763-2316 Vain/ha Abraham, M D 038840L Thomas Aldoa~ M D 017075E 6alvatore AIf~o, M D 025502E Ramesh Amra, M D 016727E Glen Danghtry. D O 06006776E Nlcolau DaCosta, M D 053288-L ) Jan Dubm, D O OS 0(}6991L Marly~ Hasqou, M D 072553L John P Judson. M D 038368-E Rmhard Luley. M D 029960-E Plu[hp Magmre, M D 015063-E ) Pushpa Mudan. MD 051514L 2 3 ( )The following rn~dmlneS may cause drowsiness DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING ) Follow-up W~th ( ) Urg~ Center ( ) Family Doctor in days for ( ) Follow-up ( ) Suture removal rechecked by your physician phys~ctan trom MedicAl Records (763-2660), ii not already sent I understand that I have had e~rgency treatment only and that l may Lawrence Paul, M D 039524-L Howard Rudmck. M D 040562-L f Ran)aha Shan'aa, MD 031265-E Alan Tepks. M D 030018-E David Zimmerman, M D 005636-E b/DO vlql\r'~/.,C"4z , L THE LO 0 M I S COMPANY 850 PARK ROAD PO. BOX 7011 WYOMISSING, PA 19610-6011 PHONE 610-374-4040 FAX 610-374-6578 ]nternet www. loomisco.com April7,2004 Metzger Wickersham 3211 North Front Street Harrisburg, PA 17110 Attention: Stephanie Gratkowski VIA FACSIMILE: 717-234-9478 Re: Claimant: Daniel Ally dependent of Wazir Group No.: 7466 072-64-2799 DOLL: July-18, 2001 Dear Ms. Gratkowski: This correspondence is in response to yours dated April 7, 2004. Your correspondence states it will be reimbursing The Loomis Company $341.92. Please accept this as confirmation the plan will accept $341.92. As stated in my previous letter, please make the check payable to Pinnacle Health and forward to The Loomis Company. Should you need any additional information, please don't hesitate to contact me. Sincerely, Beth Norton Subrogation/Refund Coordinator Insurance and Administrative Services WITH OFFICES IN: WYOMISSlNG, PA' ANNAPOLIS, MD' FORT LAUDERDALE, FL · L/~{m~: USAA' UNITED SERVICES AUTOMOBILE ASSOCIATION 9800 Fredericksburg Road, San Antonio,TX 78288 METZGER/WICKERSHAM ATTN: CHERRI WMITSON 3211 NORTH FRONT STREET PO BOX 5300 HARRISBURG PA 17110-0300 April 16, 2004 Policyholder: Michael J. Placzek Reference Number: 2555034-94A-414-6775 Date Of Loss: July 18, 2001 Loss Location: Camp Hill, Pennsylvania Your Client: Daniel Ally Dear Cherri: I am pleased we have reached an amicable resolution of this matter. Please have your client sign the enclosed release, the signature witnessed, and return it as soon as possible. have Upon receipt of the signed release(s) and all court approval documents, we will issue the payment as instructed. It is my understanding you will handle the probated court matter, please let me know if this is incorrect. Under Federal Tax guidelines, we are required to report all payments made to attorneys in connection with legal services. Therefore, to avoid any delay in payment, please provide us with your Tax Id number. Thank you for your courtesy and cooperation. If you have any questions, please contact me. Sincerely, Nozma M. Gerrald Property Claims Examiner Northeast Region Phone: 1 800 531-8222 ext. 2-5023 Fax Phone: 800-531-0759 Encl: Parent Rel 2555034 414 PA - 07/18/01 - 6775 - 62 P700 PARENTS/GUARDIAN RELEASE, AND INDEMNITY AGREEMENT MernUe~ Name USAA Number L/R Number Date of Loss United Services Michael J. Placzek 2555034 414 07-18-2001 Automobile Association FOR AND INCONSIDERATIONofthepaymenttome/usofthesumof ($ 15,000.00) Fifteen Thousand Dollars and no/100 the receipt of which is hereby acknowledged, I/we, the undersigned, father and mother and/or guardian of Daniel Ally a minor, do forever release, acquit, discharge and covenant to hold harmless Michael J. Placzek and United Services Automobile Association his/her heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, conlribution, indemnification,on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which I/we may now or hereafter have as the parents and/or guardian of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or to result from a certain accident which occurred on or about July 18, 2 0 01 at or near Camp Hill, PA I/We do hereby state that said minor is completely recovered from any and all injuries sustained as a result of said accident and promise to bind myself/ourselves jointly and severally, my/our heirs, administrators and executors repaytothesaid Michael J. Placzek and United Services Automobile Association his/her heirs, successors and assigns any sum of money, except the sum above mentioned that he/she/they may hereafter be compelled to pay because of the said accident. It is further understood and agreed that this settlement is the compromise ora doubtful and disputed claim, and that this payment is not to be construed as an admission of liability on the part of Michael J. Placzek and United Services Automobile Association by whom liability is expresslydenied. I/We further agree and acknowledge that the releasees, and each of them, expressly reserve all rights of action of whatever kind against me/us, my/our heirs, executors, administrators and assigns and against said minor on account of, or in any way growing out of the above described occurrence or accident. I/We further state that I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. PENNSYLVANIA ~alules, Title 18, Section 4117 (k) {1) states: "Any person who knowingly and with intent to defTaud any insurance company (x ot~er person files an application for insurance or Executed at WITNESSES: , this day of CAUTION: READ BEFORE SIGNING Year Signature Legal Signature Meena Ally Address Print Name Signature Legal Signature Chris Ally Address Print Name RAP012-{)603 PA- D-94A o3 -06775 /62 CONTINGENT FEE AGREEMENT We, tn~ri~ ~/~ , individually and as parent(s) and natural guardian(s) of ['>~ ~.~ ~ ~,( , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent my ,5Oe, in all claims for compensation and reimbursement for personal injuries, wage loss, and economic and other damages resulting from an ~ ~5 o ~-V o ca~ that occurred on 1. Attorney's Fees: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. Expenses of Litigation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. We do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. We understand that we are responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, we may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. Document #: 234130.1 3. We hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of cimumstance of a party or for other reasons. 4. We hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecfing the claim on our behalf. 5. We further authorize our attorney to pay out of' any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers' compensation liens. 6. We agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attomey shall then have the right to rescind this Agreement. 7. We hereby further agree that if we decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon percentage fee of one-third of any ultimate recovery, whichever is greater. 8. We agree that our attorney may withdraw from this case at any time after reasonable notice to us, and we agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Document #: 182430.1 9. We also tmderstand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. 10. I understand and agree that in the event that my account is turned over for collection because of unpaid fees and/or costs/expenses, I will be responsible for payment of the costs of suit as well as reasonable attorney fees incurred in the collection of the monies owed to Metzger, Wickersham, Knauss & Erb, P.C. IN WITNESS WHEREOF, I have signed below on this t ~ day of I ~ r~ ~ ,2003. CLI~"NT: CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. A~ark D~Vere, Esquire Document #: 182430.1 -3- USAA - United Services Automobile Association PARENTS/GUARDIAN RELEASE AND INDEMNITY AGREEMENT Member Name USAA Number L/R Number I Date of Loss Michael J. Placzek 2555034 414 [ 07-18-2001 FOR AND IN CONSIDERATION of the payment to us of the sum of Fifteen Thousand Dollars and no/100 ($15,000.00), the receipt of which is hereby acknowledged, We, the undersigned, father and mother and/or guardian of Daniel Ally, a minor, do forever release, acquit, discharge and covenant to hold harmless Michael J. Placzek and United Services Automobile Association, his/her heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, contribution, indemnification, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may now or hereafter have as the parents and/or guardian of said minor, and also all claims or fights of action for damages which the said minor has or may hereafter have, either before or after he has reached his majority, resulting or to result from a certain accident which occurred on or about July 18, 2001 at or near Camp Hill, Cumberland County, Pennsylvania. It is further understood and agreed that this settlement is the compromise of a disputed claim, and that this payment is not to be construed as an admission of liability on the part of Michael J. Placzek and United Services Automobile Association by whom liability is expressly denied. We further agree and acknowledge that the releasees, and each of them, expressly reserve all rights of action of whatever kind against us, our heirs, executors, administrators and assigns Docura~nt#303430.1 and against said minor on account of, or in any way growing out of the above described occurrence or accident. We further state that we have carefully read the foregoing release and know the contents thereof, and we sign the same as our own free act. The payment of $15,000.00 cons.:it,~tes damages on account of personal injury or sickness in a case involving physical injury or sickness within the meaning of IRC §104(a)(2). This Settlement Agreement is entered into in the State of Pennsylvania and shall be construed and interpreted in accordance with its laws. PENNSYLVANIA Statutes, Title 18, Section 4117(k)(1) states: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purposes of misleading, infomtion concerning any fact material thereto commits a fi'audulent insurance act, which is a crime and subjects such person to criminal and civil penalties." Executed at WITNESSES: ,this day of ,2004. CAUTION:READBEFORESIGNING Signature Legal Signature Meena Ally Address Print Name Signature Legal Signature Chris Ally Address Print Name Document #303430.1 VERIFICATION I, Chris Ally, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: May 14, 2004 Chris Ally VERIFICATION I, Chris Ally, as parent and natural guardian of minor PlaintiffDaniel Ally, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have retied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relafmg to unswom falsification to authorities. Dated: 1*lay 14, 2006 Chris Ally, as parent and natural guardia~ to Daniel Ally VERIFICATION I, Meena Ally, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiffs Compromise Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Pla'mtiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: May 14, 2004 Meena Ally VERIFICATION I, Meena Ally, as parent and natural guardian of m'mor PlaintiffDaniel Ally, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settl~nent are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Plaintiff's Compromise Settlement, and to the extent that it is based upon information, which I have given to counsel, it is tree and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Plaintiff's Compromise Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Plaintiff's Compromise Settlement are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: May 14, 2004 Meena Ally, as parent anddaatural guardian to Daniel Ally VERIFICATION The undersigned hereby certifies that he is the attorney for Plaintiff Daniel Ally, by Chris and Meena Ally, as Daniel's parents and natural guardians and that the facts in the foregoing Petition for Approval of Minor Plaintiff's Compromise Settlement are Ixue and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Plaintiffs Compromise Settlement are as known to the undersigned as to the clients minor Plaintiff Daniel Ally, by Chris and Meena Ally, as his parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. §4904 relating to unswom falsification to authorities. Dated: May 17, 2004 302775-1 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a tree and correct copy of Petitioner's Petition for Approval of Minor Plaintiffs Compromise Settlement with reference to the foregoing action by first class mail, postage prepaid, this 17~' day of May, 2004 on the following: Norma Gerrald Property Claims Examiner United Services Automobile Association 9800 Fredericksburg Road San Antonio, TX 78288 Clark DeVere, Esquire 302775-1 MAY ~ 9 ~004 INRE: DANIEL ALLY IN THE COURT OF COMMON PLEAS OF CUMBERLAlX[D COUNTY, PENNSYLVANIA No. CIVIL TERM ORDER AND NOW, this d~/~ is scheduled for the ~$: '~0 ~l.m. in ~OJ0/J~-w~ CCi day of ~ __, 2004, a ~ } :~ t::1. dayof ~L ,2004 at ! -~O. ~ before Judge ~ ~o=~' ~or e~ti~io= ~,~ Document #302775.1 IN RE: DANIEL ALLY, a minor Born: May 15, 1990 : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : 04~2243 CIVIL TERM ORDER OF COURT AND NOW, this. I ~,~"J~ day of June, 2004, IT IS ORDERED: (1) Approval of the settlement of this minor's claim for $15,000 for Daniel Ally, a minor, born May 15, 1990, IS GRANTED. (2) From the settlement, a counsel fee of $3,750, IS APPROVED. (3) From the settlement $341.92 shall be paid to satisfy a lien for medical expenses to Loomis insurance Company. (4) Costs of $55.50 are approved to be paid to plaintiff's counsel for the filing fee. ~ (5) $500.00 is allocated to Chris Ally, the father of Daniel Ally, for the sole purpose of purchasing a computer for Daniel Ally? (6) The net proceeds of $10,352.58 shall be placed in a federally insured interest bearing investment in M&T Bank, in the name of Daniel Ally, born May 15, 1990. (7) The account shall contain the following notation: "NO WITHDRAWAL CAN BE MADE PRIOR TO DANIEL ALLY, BORN MAY 15, 1990, OBTAINING HIS MAJORITY EXCEPT BY AN ORDER OF A COURT OF COMPETENT JURISDICTION." ~ The remaining costs sought by counsel are disapproved as overhead. See Shuler v. Seibert, 42 Cumberland L.J. 242 (1993). 2 We will not approve costs sought by the father for the responsibility of parents, private remedial education. That is (8) Chris Ally is authorized to sign any release necessary to effectuate this settlement, and to then settle and satisfy the docket. (9) Counsel for plaintiff, Clark DeVere, Esquire, shall file with the Prothonotary, and forward a copy to this chambers, proof of compliance~ ,,~ th,~rder. Edgar B. Clark DeVere, Esquire / For Petitioner :sal ~- lC- o 1N RE: DANIEL ALLY 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA No. 04-2243 CIVIL TERM CIVIL TERM PROOF OF DEPOSIT In accordance with Pennsylvania Rule of Civil Procedure 2039 and Judge Edgar B. Bayley's Order of June 16, 2004, the undersigned is filing a photocopy of the Certificate of Deposit of $10,352.58 of the settlement proceeds in the above., matter which were deposited on July 16, 2004 at M & T Bank in the name of the minor Daniel Ally, "no withdrawal can be made prior to Daniel Ally, Born May 15, 1990, obtaining his majorky except by an Order of Court of competent jurisdiction." The photocopy of the Certificate of Deposit is attached hereto as Exhibit METZGER, WICKERSHAM, KNAUSS & ERB, P.C. By: Clark DeVer-~, Esquire Attorney I.D. No. 68768 3211 North Front Street P.O. Box 5300 Harrisburg, PA 17110-02100 (717) 238-8187 Attorney for Plaintiff Dated: August 2, 2004 $09500-1 MANUFACTURERS AND TRADERS TRUST COMPANY *** CERTIFICATE OF DEPOSIT *** DATE: 07/16/2004 OFFICE: Capital Harrisburg Office DANIEL ALLY, MINOR CHRIS ALLY, GUARDIAN SURROGATE COURT CLERK 3411 HAWTHORNE DRIVE CAMP HILL PA 17011 ACCOUNT NUMBER: OPENING DEPOSIT: ACCOUNT TERM: INTEREST RATE: ANNUAL PERCENTAGE YIELD: MATURITY DATE: 31003913208946 $10,352.58 48 Months 3.20 3.25 07/16/20¢,8 Thank you for choosing M&T Bank. NOT TRANSFERABLE (AS DEFINED IN 12 CFR 204) "~ NON-NEGOTIABLE *~ Member FDIC New Accnunt 07/16/04 - ACCOUNT TITLE AND ADDRESS DANIEL ALLY, MINOR CHRIS ALLY, GUARDIAN SURROGATE COURT CLERK 3411 HAWTHORNE DRIVE CAMP HILL PA 17011 MANUFACTURERS AND TRADERS TRUST COMPA~N~/' CONSUMER DEPOSIT ACCOUNT OPENING REQUEST OFFICE OF ACCOUNT 4306 Capital Harrisburg Office ACCOUNT NUMBER 31003913208946 ACCOUNT 'IYPE 48 - 60 Month CD CUST 1 PHONE # (717)763-8508 CUST 1 SSN: 053783820 BIRTHDATE 05/13/1990 CUST 2 SSN: 072642799 BIRTHDATE 09/15/1970 By signing below, I (we) (1) request that M&T Bank open in my (our) names thc deposit acco,ant requested below with the features requested, and (2) acknowledge receipt of, and agree to all pmv~sions of~ the General Deposit Account Agreement, Availability Disclosure for Consumer Deposit Accounts, the Specific Features and Terms containing information about the account, the applicable fee schedule and, if the account is a Jumbo Certificate of Deposit, the Agreement for Telephone Instructions. By signing below, I (we) ack~owlndge and agree that if the account is opened in the names of two or more individuals, unless the account is a fiduciary or custodial account, it will be a Tenancy By The Entireties Account With Right of Survivorship if the sole individuals in whose name the account is opened are husband and wife, and, in all other cases, a Joint Account With Right of Survivorship. Certification. Under penalties of perjury, I (customer 1) certify: (1) that the number shown on this form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and (2) that I am not subject to backup withholding because (a) l am exempt from backup withholding; or (b) I have n.~t b. een..n, otified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result o! a tauure to report all interest or dividends, or (c) the/RS has notified me that I am no longer subject to backup withholding; and (3) that I am a U.S. person (including a U.S. resident alien). Certification Instructions - You must cross out item (2) above |lyon have been notified by the IRS that ~ou are currently subject to backup withholding because of underreporting interest or dividends on your tax return. (Also see Part III - Certification under Specific Instructions on the separate W-9 form.) The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding. , SIGNATURE CUST 1 DATE ,,,SIGNATURE CUST 2 DATE S[GNATURE CUST 3 DATE SIGNATURE CUST 4 DATE IDENTIFICATION: CUST I DL PARENT CUST 2 DL PA CUST 3 CUST 4 OPENING AMOUNT $10,352.58 DATE 07/16/I)4 CHECKING: Relation.strip Package Tmr~fer Interest to Account Safecheck? SAVINGS: Interest Rate PR CLUB: Transfer to Account TIME DEPOSIT: Initial Term 48 Automatically Renewable? Interest Rate Interest Check? Basis Points PR Approval P[omotional Code Original - Account Service~ Copy - Branch WPA001 (03104) ACCOUNT SPECIFICS Interest Rate PR OD Funding Account Transfer hate~est to Account Months Initial Maturity Date YES Final Matudty Date 3.2000 Transfer Interest to Account Interest Cycle 00 PR Service Charge Waive Code 07/16/08 ZIF *%, z RSMU CO ACTION FAD PROD CODE CDA CLASS: I (1,2,3) __ RSHO 2 FSS RST HARD HOLD INQ/MAINT 04/07/22.11.1~.23 96 OP ESRN HS ACTION SUCCESSFUL COlD ACCT 31003913208946 SHORT NAHE TYPE: 13 SEQ CURRENCY TYPE CODE ........... REASON CODE ......... SPECIAL COMMENTS LINE 1 LINE 2 RESTRAINT REASON LINE 1 LINE 2 DATE PLACED ............ DATE EXPIRES ........... STATUS CODE ............ UNDER COURT ORDER, NO NITHDRAN ALLONED NITHOUT COURT APPROVAL STATUS CODE VALUES : I = ACTIVE A = ACTIVE PAID 2 = DELETE B = DELETE PAID PF: 2-CONT 4-CHG 5-FAD 6-INQ 9-NXT ..-DEL ..-ADD CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.C., hereby certify that I served a tree and correct copy of Plaintiff's; Proof of Deposit with reference to the foregoing action by first class mail, postage prepaid, this 2ncl day of August, 2004 on the following: Norma Gerrald Property Claims Examiner United Services Automobile Association 9800 Fredericksburg Road San Antonio, TX 78288 The Honorable Edgar B. Bayley Court of Common Pleas of Cumberland County Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 METZGER, WICKERSHAM, KNAUSS & ERB, P.C. Clark DeVere, E~u~re 309500-1